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PRINT THE COMPLETE FORM & COMPLETE IN IT'S ENTIRETY
BE SURE TO PAY SPECIAL ATTENTION TO THE FOLLOWING AREAS
   
SPECIAL INSTRUCTIONS FOR ALL APPLICANTS:

1. Print or type each name as you want it to appear on your Identification Card(s).
2. Provide the complete address of your residence outside the US and any US mail forwarding address.
3. All Applications must be fully completed, signed and dated to be considered. Questions answered YES in Section 3 must include treatment date, name, address and telephone number of attending physician, diagnosis, prognosis, and present course of treatment. (If additional space is necessary, please use the space provided in the Additional Information Section 7.)
4. Annual premiums may be paid by check, money order, VISA, MasterCard, or American Express credit cards. IMG will not accept checks or money orders for quarterly or semi-annual payment modes. These payment modes are only accepted with pre-authorization to debit your credit card on the due date of your premium installment.
5. An optional $20 fee may be paid in addition to the premium to have your Certificate expressed mailed to you after approval.
   

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